© 2010 NHS Education Scotland The Primary Care Trigger Tool: Clinical case study

The Primary Care Trigger Tool

Example of a General Practice Medical Record

Ms. Annette Curtain, D.O.B. 01/01/1935

This fictional medical record is intended to be used as part of the practical training in the use of the trigger tool method. It purposefully imitates an authentic printed summary sheet that the vast majority of practices generate on a daily basis. The correspondence and investigation results that are included have been designed to represent printed copies of documents as they would commonly be used in Scotland’s general medical practices.

The following should be taken into consideration when attempting a review:

Review only the three full calendar months February-April 2010 The maximum time limit of this exercise should be twenty minutes Record extracted data on a trigger tool proforma. Incidental findings and

descriptions can be entered into the space provided.

The trigger tool process is described in a separate guide. Some of the key points were:

The focus is harm, not error. You do not necessarily have to find every trigger. Most harm incidents will have

more than one trigger helping to detect it.

The trigger tool review process may be facilitated by remembering five questions:

Can a trigger(s) be detected? Did harm occur? What was the severity of the harm? Was the harm incident preventable? Where did the harm incident originate?

A full discussion of the practical findings of this case, including the number and type of triggers and harm events are available. Disclaimer This complete medical record is fictional. It was created by NHS Education Scotland to support training in the use of the Trigger Tool method. The patients, healthcare professionals, providers and all other persons referred to are entirely fictional. Any resemblance to any person (living or dead) is entirely unintentional. This training material is the property of NHS Education Scotland and may be used free of charge on request from nes@nes.scot.nhs.uk.

Curtain, Annette Report valid on 14/06/2010, 16:15 Welcome Medical Practice DoB: 01/01/1935 Fictional case notes

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Registration

Mrs. Annette Curtain Service Code: Temporary Resident

39 Main Street D0B: 01/01/1935

FORTH, LANARK Age: 75

Telephone: 01555 555 555

Contact: Mrs. Jones ContactRelship:

Daughter

Email:?

CHI Number: 5555555555 NHS Number:? Dispensing: No

Patient ID: Road: 0 Water: 0 FootPath: 0

Occupation: Pensioner Marital Status: Single

Registered GP: Dr Carl De Wet Seen By GP: Dr Carl De Wet

Repeat Consultation: ? Acute Consultation: 02/06/2010

Registered: 01/09/2009 Confirmed: 14/09/2009 Records Received:27/09/2009

BMI: 33.7 Height: 1.57 m Weight: 83kg BP: 142/78

Parity: 1 Gravida: 2

SCI-DC Consent Given: Yes

Priority Clinical I User Marker

Date

Recorded

Start

Date

Priority Description Modifier

06/05/2010 None High Allergic drug reaction NOS

Freetext: Cocodamol

17/02/2010 None High Allergic drug reaction NOS

Freetext: Amlodipine

30/09/2009 None High Hypertensive disease

04/05/2007 None High H/O: diabetes mellitus

Freetext: diet controlled

Repeat Medication Intervals

Drug/Preparation Quantity/Dose/Frequency Start Last Pres. Review CMS Int.

Ramipril TABS 2.5MG 28 one tab dly 02/06/2010 02/06/2010 30d 52w w.

Paracetamol TABS 500MG 112 2 tabs 4x day 02/06/2010 02/06/2010 28d 52w w.

Adverse Reactions

Read Code Description

SN52. Drug hypersensitivity NOS 17/02/2010

ADR Description Amlodipine

SN52. Drug hypersensitivity NOS 06/05/2010

ADR Description Cocodamol

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Clinical I User Marker

Date Recorded Start Date Priority Description Modifier

03/03/2010 None Low Alcohol intake within recommended sensible limits

03/03/2010 None Low Assessing cardiovascular risk using SIGN score

03/03/2010 None Low Avoids even trivial exercise

03/03/2010 None Low Ex smoker

03/03/2010 None Low FH: Diabetes mellitus in first degree relative

03/03/2010 None Low Influenza vaccination

03/03/2010 None Low Lifestyle counseling

03/03/2010 None Low No FH: lschaemic heart disease

03/03/2010 None Low Pneumococcal vaccination contraindicated

03/03/2010 None Low Smoking cessation advice

09/09/2008 None Low Medication review done

07/09/2008 None Low Consent given for pandemic influenza vaccination

07/09/2008 None Low PANDEMRIX - first influenza A(H1N1v) 2009 vac given

07/09/2008 None Low Fast alcohol screening test

07/09/2008 None Low Pneumococcal vaccination given

07/09/2008 None Low Influenza vacc consent given

07/09/2008 None Low Influenza vaccination Left Arm - Batch Number: S31 Exp: 6/10

07/09/2008 None Low Smoking cessation advice given

Last Encounter Lorraine Urquhart Date: 02/06/2010

General review - BP 145/85. Plan - bloods done. D/W GP and increase Ramipril to 2.5 mg dly = pt has her own supply and will double dose

Acute Prescriptions

Drug/Preparation Quantity/Dose/Frequency Date

Flucloxacillin CAPS 500MG 28 one cap 4x day 12/03/2010

Ramipril CAPS 1.25MG 28 one caps dly 22/03/2010

Co-Codamol 3Omg/500mg TABS 60 1 or 2 Tabs every 4 to 6 hours 05/05/2010

Paracetamol TABS 500MG 50 1 or 2 Tabs 06/05/2010

Ramipril CAPS 10MG 28 1 cap daily 17/02/2010

Amlodipine TABS 5MG 28 one tab dly 05/02/2010

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Inactive Repeat Drugs

Drug/Preparation QuantitylDoselFrequency Start Last Pres Review CMS

Int.

Bendroflumethiazide TABS 2.5MG

56 1 Tab in the morning 09/09/2008 16/02/2010 28d 26 w.

Ramipril TABS 10MG 28 one tab dly 17/02/2010 17/02/2010 30d 52w w.

Screening

None

Referrals

Date Rec Priority Ref. appt Provider Specialty Reason for referral Ref. by Attendance

type

Acute/Inactive Care Management

Type Name Last Review Recall Next review Num Session

Acute 1st SPICE Index 02/06/2010 N/A N/A 1

Chronic SPICE smoking 02/06/2010 Inactive 1

Chronic SPICE basic health

values

02/06/2010 Inactive 1

Chronic SPICE hypertension 02/06/2010 Inactive 1

Chronic SPICE Diabetes 02/06/2010 Inactive 2

Palliative Care

Associates

Title Forename Surname Relationship Relationship Type

Associate Of

Title Forename Surname Relationship Relationship Type

Clinical Values

Date Value Type Value

03/03/2010 Diastolic 78

09/09/2008 Height 1.57

03/03/2010 Systolic 142

19/03/2010 Weight 83

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F3 Clinical Notes

Date Con Prov F3 Clinical Notes

02/06/2010 ☺ PN General review - BP 145/85. Plan - bloods done. D/W GP and increase Ramipril to 2.5 mg dly = pt

has her own supply and will double dose

28/05/2010 ☺ GP Pain in knee persists. Unable to sleep and generally fed up’. Exam - as before Plan - advised on physio

self-referral. Consider orthopaedic referral if no improvement

06/05/2010 ☺ GP Tried Cocodamol, but faint/dizzy and generally unwell. Plan - stop. regular Paracetamol

05/05/2010 ☺ GP Pain in left left knee for 1/52, with assoc stiffness Ex - normal gait, reduced ROM but no effusion,

crepitus IMp - OA Plan - Cocodamol

04/04/2010 ☺ PN BP 150/80 Plan - increase ramipril to 2.5 mg dly, UCE checked

22/03/2010 ☺ GP See prey entries - UCE normal, BP 160/95 x2. Plan - restart Ramipril 1.25 mg and review with PN -

titrate carefully

19/03/2010 ☺ PN Wrist redness now almost completely gone - bruising on arms fading.

BP 145/85,

Bloods done

15/03/2010 GP Redness wrist resolving, but copious diarrhoea -tolerating fluids. Imp: likely AAD Plan - stop

Flucloxacillin, review if needed

12/03/2010

GP See prey entry - Ex: left arm tracking, redness and tenderness. Systemically stable. Imp - cellulitis, sec

to IVI Plan - oFlucloxacillin

12/03/2010 GP Review phone call. Patient discharged from hospital - ‘much better’ but concerned redness and pain

left wrist ?IVI site Plan - review (HV)

04/03/2010

GP Weakness, fatigue and occasional palpitations. Lives alone with daily, private home help Ex - BP

120/75, p55R, respiration clear, mobilizing but staggering. Imp - likely hyperkalaemia Plan - d/w

MOC and admit for observation

03/03/2010 GP Lab phoned with blood results - K=6.5, non-haemolyzed. Plan - phone patient - no response

03/03/2010 ☺ PN BP 135/75. Bloods taken as per GP request for UCE, eGFR. SPICE done

17/02/2010 ☺ GP See prey entry - unacceptable, bilateral ankle swelling. Ex - BP 150/88 l=r Imp - oedema sec to

Amlodipine Plan - discontinue and start ACE, with PN f/u for UCE 2/52

05/02/2010 ☺ GP Bilateral, dull headaches, worsening over last few weeks. Ex- BP 170/90 sit=stand x2 readings Imp -

uncontrolled hypertension Plan - add amlodipine, review 2/52

09/09/2008 ☺ GP High BPs x3 - referred by PN. Plan - commence diuretic

07/09/2008 ☺ PN BP 165/95, 175/105. SPICE, general advice – will make appt to see GP to discuss blood pressure

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